General Health - Bluffton Aesthetics...Common side effects include temporary redness and mild...

3 Plantation Park Drive | Bluffton, SC | 843-505-0584 | www.blufftonaestetics.com

Name: Occupation:

Address: Date of Birth:

City: State: Email:

Phone: Emergency Contact:

How did you hear about us? Referral Name:

General Health 1. Rate your level of stress: (5 = highest, 1= lowest) 5 4 3 2 1

2. Are you pregnant or nursing? Yes No

3. Do you wear contact lenses? Yes No

4. Do you smoke? Yes No How many cigarettes per day? Drink? Yes No ___

5. Please list any accidents or surgeries in the last 9 months:

6. Do you have any metal implants, a pacemaker or body piercings?

7. List the medications you are currently taking:

Prescription Over the Counter

Health History Circle All That Apply

Heart Condition Lymph Edema Herpes/Shingles

High Blood Pressure Low Blood Pressure Numbness/Tingling

Sinus Problems Allergies Chronic Pain Varicose Veins Rashes

Jaw Pain/TMJ Blood Clots Constipation Sprains/Strains Diabetes

Gas/Bloating Headaches Arthritis Spasms/Cramps

Broken/Fractured Bones Pregnancy ( ____ weeks)

Fatigue/Sleep Disorder Depression/Anxiety

CancerOther (explain): Undergoing Cancer treatment

It is my choice to receive these Services from Bluffton Aesthetics. I have completed this form to the best of my knowledge. I have stated all medical conditions that I am aware of and I will update the staff at Bluffton Aesthetics of any changes to my health status.

If I am unable to make a scheduled appointment, I agree to cancel the appointment 24 hours in advance by phone, unless I have an emergency. In this case I will call ASAP to reschedule my appointment. If I miss a scheduled appointment without giving 24hour notice, I agree to pay the missed appointment fee that applies.

Name Date

Skin Care 1. Are you under the care of a dermatologist? Yes No

2. Do you use: Accutane Retin A Renova Adapalene Other prescription skin products

3. Have you had a: Chemical Peel Microdermabrasion Botox Other resurfacing treatments

4. Are you currently using any products that contain: Glycolic Acid Lactic Acid Hydroxy Acid Vitamin A

5. Do you have any skin sensitivities or irritants

Skin Maintenance

Products You Use: Soap Cleanser Toner Moisturizer Exfoliator

Masque Sunscreen __UVA UVB SPF __________

Other: _________________________________________

Skin Type: Oily/Congested Dry/Dehydrated Sensitive/Redness Acne Sunburned

Do you have any of these conditions?

Rosacea Acne Shingles HIV Herpes Eczema Claustrophobia

Psoriasis Iodine or Shellfish

Have you been tanning, used spray tan or self tanner in the last 24 hours? Yes No

Are you going or coming from a vacation? Yes No

What are your skin care goals?

3 Plantation Park Drive | Bluffton, SC | 843-505-0584 www.blufftonaesthetics.com

CONSENT FOR LASER/LIGHT BASED TREATMENT

I authorize Dr. Charles Joseph Nivens and the dedicated staff at Bluffton Aesthetics to perform laser/ pulsed light cosmetic treatments on me, including but not limited to deep tissue heating, hair removal, treatment of pigmented lesions, vascular lesions, acne, and/or wrinkles or tattoo removal. I understand that the procedure is purely elective, that the results vary with each individual, and that multiple treatments may be necessary.

I understand that: Serious complications are rare, but possible. Common side effects include temporary redness and mild "sunburn" like effects that may last a few hours to 3-4 days or longer. Pigment changes, including hypopigmentation (lightening of the skin) or hyperpigmentation (darkening of the skin), lasting 1-6 months or longer may occur. In addition, freckles may temporarily or permanently disappear in treated areas. Other potential risks include crusting, itching, pain, bruising, burns, infection, scabbing, scarring, swelling, and failure to achieve the desired result. Lasers/intense light can cause eye injury and protective eyewear must be worn during treatment. I understand that a series of treatments may be required to achieve the desired result.

I understand that sun or tanning lamp exposure and not adhering to the post-care instructions provided to me may increase my chance of complications.

I consent to photographs being taken to evaluate treatment effectiveness, for medical education, training, professional publications or sales purposes. Photographs revealing my identity will not be used without my written consent. If my identity is not revealed, these photographs may be used and displayed publicly without my permission.

Before and after treatment instructions have been discussed with me. The procedure as well as the potential benefits and risks have been explained to my satisfaction. I have had all my questions answered. I freely consent to the proposed treatment.

Patient's Signature: __________________________________________________________________

Date: ___________________

Print Name: __________________________________________________________________________

Witness Signature: ____________________________________________________________________

Date: ___________________

Print Name: _________________________________________________________________________

Initial Here and date each treatment.

#2______________ #3_____________ #4 ____________ #5____________ #6_________ _

Cosmetic Procedure Contract

I, _____________________________________, agree to the treatment plan and fees regarding the following laser/light source procedure(s) discussed with me by the staff at Bluffton Aesthetics Signing this contract does not obligate me to have this procedure(s) performed. It is designed to inform me of the costs of the procedure(s) and the policies involved in cancellation and payment.

The following fees have been quoted and are expected at time of treatment:

Procedure(s):___________________________________________________________

Treatments Required: _______________ spaced __________ weeks apart.

Cost per Treatment: $ __________________________________________________

These fees are guaranteed until ________________________________________

I understand and accept the following financial arrangement: The entire cost of each procedure is to be paid in full at the time of service. This may be paid by cash, pre- approved check, MasterCard/VISA or Care Credit or divided between any of these payment methods. Elective cosmetic procedures are not covered by insurance.

Reservation Policy: We understand that life is busy and emergencies arise and we will understand missing one appointment, however, should a client miss an appointment or cancel a procedure less than one (1) business day prior to the scheduled time a second time, a cancellation fee of $50.00 may be charged.

Thank you for visiting Bluffton Aesthetics.

Client Signature_____________________________________Date________________

Witness Signature___________________________________ Date________________

3 Plantation Park Drive | Bluffton, S

C | 843-505-0584 | www.blufftonaestetics.com


30-SECOND QUESTIONNAIRE: COSMETIC MEDICAL TREATMENTSPlease take a few moments to answer the questions below. We are pleased to offer our valued clients most of the country’s most popular non-surgical aesthetic procedures. Let us know if you would like more information on any of these procedures. Please return to front desk after completing.

Would you be interested in Botox Cosmetic wrinkle removing therapy? Yes __ No__

If yes, which facial areas would you be interested in having treated?

Forehead ___ Crow’s Feet ___ Frown Lines (between the eyebrows) ___ Other ___

Would you be interested in Laser Hair Removal? (permanent hair reduction treatments are faster, more comfortable and more affordable than electrolysis and waxing) Yes ___ No ___

If yes, which areas would you be interested in having treated?

Face ___ Underarms ___ Bikini Line ___ Legs ___ Arms ___ Back ___ Chest ___

Other ___

Would you be interested in receiving IPL Photorejuvenation treatments? (a series of safe, effective, non-invasive treatments designed to erase or reduce skin imperfections on either the face, neck, chest or other body areas) Yes ___ No ___

If yes, which conditions are you interested in having treated?

Age Spots ___ Rosacea ___ Sun Damage ___ Spider Veins ___ Broken Capillaries ___ Fine Lines & Wrinkles ___ Enlarged Pores ___ Other ___ Facial Tightening ______

Would you be interested in a FREE Skin Care Consultation? Yes ___ No ___

Are you interested in treating fine lines and Wrinkles? Yes____ No____

Name ______________________________________________

Cell Phone: __________________

Email: _____________________________________________________

After completing, please return to the Front Desk. Thank you!


Pre and Post Treatment Instructions for Resurfacing Procedures Wrinkles, Scars and Stretch Marks

Before your Resurfacing Treatment Avoid all sun exposure, self tanning creams, spray tans and tanning beds for at least two

weeks prior to each fractional resurfacing treatment. A sunscreen with SPF 20-30 pluszinc oxide or titanium dioxide should be worn throughout the treatments.

Your laser procedure may include more than one treatment. We will present a treatmentplan for you upon consultation and evaluation of your response to the laser system

Please discontinue the following products two weeks prior to surgery: Aspirin, Motrin,Aleve, Ibuprofen, Excedrin, Vitamin E, Ginko, St. John’s Wort and any photosensitivedrugs such as Tetracycline, Minocycline with the permission of your primary caredoctor.

Active skin care products such as Retin A, Retinol, Renova, glycolic acid products, nightcreams with alphahydroxy acids should be discontinued throughout thesetreatments. Mild cleansers, toners, moisturizers may be used immediately aftertreatment.

You will be asked to remove your make up (can be done at clinic) and jewelry before aprocedure. Contact lenses may be worn.

After your Resurfacing Treatment Application of cool gel packs and topical creams prescribed immediately following

treatment can help improve post treatment itchiness and stinging that may occur.

• Edema, and sometimes blanching, is expected immediately post treatment and generallyresolves in 24-48 hours. It may last up to 3-5 days in some clients.

• Clients may experience significant redness, broken capillaries or bronzing in thetreatment area or 1-3 days after treatment. This may persist in a mild form for severalweeks particularly in areas other than the face.

• Gentle cleansing and use of non-irritating cosmetics is permitted after treatment. Theuse of Retinoids (Retina A, Renova) should be avoided during the treatment period.

• New skin will begin to form and it is essential to avoid injury and sun exposure at leasttwo weeks following treatments. It is highly recommended that clients use a sunscreenwith SPF 30 or higher containing UVA/UVB protection along with a sun blocker such aszinc oxide or titanium dioxide between treatments.

• Once the treatment area has healed, some itching or dryness may occur. This willgradually clear. The use of non-irritating moisturizers may provide some relief.

If you have any questions or concerns, please call our offices at 843-505-0584.


Instructions for Photorejuvenation and Sun Spot Treatment

Before your treatment…

• Avoid sun exposure, self-tanning products and tanning beds for at least two weekprior to IPL treatment.

• Please remove all jewelry.

• Wear loose clothing.

• Your sunspot removal may include one to four treatments spaced four weeksapart. Your clinician will present a treatment plan for you upon consultation andevaluation of your response to the laser/light system.

• A cold roller will be used to make the treatment more comfortable.

• You may resume normal daily activities immediately following your lasertreatment.

After your treatment…(Follow these directions for one week after each treatment)

• The IPL treated area may look crusty or like particles of dirt where the spot wastreated. The area should be cared for as a burn, some crusting may occur andshould heal in 7-10 days.

• Apply aloe vera gel twice daily for one week.

• Take Tylenol per packaging directions as long as needed for discomfort.

• No shaving over treated area as long as area is red and or swollen.

• Avoid all sun exposure, self-tanning products and tanning beds between lasertreatments.

• Apply a broad spectrum UVA/UVB sunscreen with a SPF-30 daily to treated areaif in the sun for at least six months following the laser treatment.

• Avoid swimming pools or hot tubs to prevent infection.



Instructions for Facial Veins/Angiomas Treatments

Before your treatment

• Avoid all sun exposure and tanning beds for at least two weeks prior to IPL treatment. Asunscreen with SPF 20-30 plus zinc oxide or titanium dioxide should be worn throughoutthe treatments.

• Your laser procedure may include four or five laser appointments. We will present atreatment plan for you upon consultation and evaluation of your response to the lasertreatment.

• Please discontinue the following products two weeks prior to each procedure: Aspirin,Motrin, Aleve, Ibuprofen, Excedrin, Vitamin E, Ginko, St. John’s Wort and anyphotosensitive drugs such as Tetracycline, Minocycline, with the permission of yourprimary care doctor.

• Active skin care products such as Retin A, Retinol, Renova, glycolic acid products, nightcreams with alphahydroxy acids should be discontinued throughout thesetreatments. Mild cleansers, toners, moisturizers may be used immediately aftertreatment.

• You will be asked to remove your make up (can be done at clinic) and jewelry before aprocedure. Contact lenses may be worn.

After your treatment …(follow for one week after your laser/ light treatment)

• Your skin may appear red or blotching in the treated area for 24-48 hours after the lasertreatment. You may temporarily experience a bumpy appearance. Please do not applymake up if area is still red. Once there is no sign of redness, make up may be applied.

• Wash treated area gently with a mild cleanser or soap and water.

• Apply post op gel twice daily to treated area. Take Tylenol per packaging directions asneeded for discomfort.


• You may experience swelling of the eyes and face that may persist for 2-4 days. Sleepwith two pillows at night and apply ice as needed for swelling.

• Avoid all sun exposure and tanning beds between IPL treatments.

• Apply a broad spectrum UVA/UVB sunscreen with SPF-24/zinc or titanium oxide daily totreated area if in the sun for at least six months following the IPL treatment.



Instructions for Laser/ Light Hair Removal Treatments

Before your treatment… • Shave area to be treated the morning of the IPL treatment. Hair should be shaved

cleanly. No waxing, tweezing or depilatories one month prior to treatment. Shaving thehair will manage hair between treatments.

• If patient has a history of Herpes, prophylactic medications may be prescribed one weekprior to treatment.

• Do not tan or use self-tanning products as they may cause adverse effects. Stay awayfrom aspirin or Aleve, ibuprofen, Advil or Motrin and Vit E one week before a treatment.

• Wear loose fitting clothing that allows comfort and modesty to the area to be treated.

• Please remove all jewelry.

• No restrictions in normal daily activities following a hair laser treatment.

After your treatment … (follow for one week after your treatment) • Wash treated area gently with soap and water.

• Apply an Aloe Vera Gel twice daily to treated area.

• Take Tylenol per packaging directions as needed for discomfort.

• No shaving over treated area as long as area is red and or swollen. Hair may remain forup to two weeks following your treatment. You may use a Loofa to remove loose hairafter a treatment.

• Apply a broad spectrum UVA/UVB sunscreen with a SPF – 30 and zinc or titaniumdioxide daily to treated area if in the sun for at least six months following the lasertreatment.

• Avoid hot tubs, swimming for one week afterward as chemicals can cause infection.

• Your skin may appear red or blotchy in the treated area for 24-48 hours after the lasertreatment.

• If a blister appears, apply Aloe Vera gel to blistered area until resolved. Keep clothingfrom rubbing blistered area.



Instructions for Rosacea Procedure

Before your treatment • Avoid all sun exposure and tanning beds for at least two weeks prior to laser

treatment. A sunscreen with SPF 20-30 plus zinc oxide or titanium dioxide should beworn throughout the treatments.

• Your laser procedure may include four or five laser appointments. We will present atreatment plan for you upon consultation and evaluation of your response to the intensepulsed light system.

• Please discontinue the following products two weeks prior to each procedure: Aspirin,Motrin, Aleve, Ibuprofen, Advil, Excedrin, Vitamin E, Ginko, St. John’s Wort and anyphotosensitive drugs such as Tetracycline, Minocycline, Zithromax, Cipro with thepermission of your primary care doctor.

• Active skin care products such as Retin A, Retinol, Renova, glycolic acid products, nightcreams with alphahydroxy acids should be discontinued throughout thesetreatments. Mild cleansers, toners, moisturizers may be used immediately aftertreatment.

• You will be asked to remove your make up (can be done at clinic) and jewelry before aprocedure. Contact lenses may be worn.

After your treatment …(follow for one week after your treatment) • Your skin may appear red or blotching in the treated area for 24-48 hours after the laser

treatment. You may temporarily experience a bumpy appearance. Please do not applymake up if area is still red. Once there is no sign of redness, make up may be applied.

• Wash treated area gently with a mild cleanser or soap and water.

• Apply post op gel twice daily to treated area. Take Tylenol per packaging directions asneeded for discomfort.


• You may experience swelling of the eyes and face that may persist for 2-4days. Swelling is normal and indicates a good treatment response. Sleep with twopillows; apply ice bag before bed and after rising.

• Avoid all sun exposure and tanning beds between laser treatments. Apply a broadspectrum UVA/UVB sunscreen with SPF-24/zinc or titanium oxide daily to treated area ifin the sun for at least six months following the laser treatment.

• Avoid alcohol, spicy foods and caffeine and exercise for one day after a procedure.


General Health - Bluffton Aesthetics...Common side effects include temporary redness and mild...

Documents

Transcript of General Health - Bluffton Aesthetics...Common side effects include temporary redness and mild...